Outcome of burn injury and its associated factors among burn patients attending public hospitals in North Showa Zone, Ethiopia: A cross-sectional study

Burn injury is a major contributor to morbidity and mortality in developing countries. In Ethiopia, the outcome of burn injuries and associated factors among burn patients were not clearly described. To assess the outcome of burn injuries and its associated factors among burn patients attending public hospitals in the North, showa Zone, Ethiopia. An institution-based cross-sectional study was conducted among 420 burn patients in public hospitals of the North showa, zone. Systematic random sampling was used to select study participants. Structured checklists were used to extract data from burn patients’ medical records. Data was entered using Epi-Data version 4.6. Data was analyzed using SPSS version 25. A p- value of ≤ 0.05 in the multivariable logistic regression was used to declare a significant association. In this study, the prevalence of discharges with complications was 40.9% (95% CI: 36.5–45.6). The odds of developing complications among patients having pre-hospital intervention were nearly four times the odds of not having the intervention (AOR = 3.8, 95% CI, 1.11–13.25). The odds of developing complications among patients having scalds were four times the odds of not having scalds (AOR = 4.3, 95% CI, 1.52–12.32). A patient who received fluid and electrolytes was 76% less likely to develop the outcome of burn injury discharged with burn complications. Patients with TBSA less than 20% were 66% less likely to be discharged with complications compared to patients with TBSA greater than 20%.: This study demonstrates a significantly higher level of outcome for patients with burn injuries who were discharged with complications, leading to death and other bad outcomes. Therefore, stakeholder would more emphasis in health education on prevention of burn injuries, first aid treatment of burn, treatment of the cause of burns, and providing fluid and electrolytes.

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Introduction
Burn is a term used to describe skin and tissue damage brought on by a fire, scald, electrical shock, chemical, or radioactive radiation.Due to the prolonged hospitalization for rehabilitation and the treatment of wounds and scars, burns are the most expensive traumatic injuries [1].Large burn victims have many of the same physiological reactions as victims of major trauma, particularly venous thromboembolism [2].It is one of the frequent and unpleasant forms of trauma in addition to being a substantial worldwide health problem that increases morbidity and death and causes significant material, psychological, and financial damage [3].Burns are damaging wounds that are linked to morbidity, a reduction in quality of life, and emotional wellbeing [4].Mortality and morbidity from burns remain high, particularly in developing countries [5].These areas are also areas where the lack of socio-economic growth and geopolitical instability create additional barriers not only to the delivery of health care, but also to the acquisition of continuous professional development [6].Burns are estimated to be the root cause of 180,000 deaths worldwide, most of which currently occur in low-and middle-income countries [7].Burns are the fourth leading cause of trauma in the world and are common in developing countries [8].Burn injury incidence and mortality affect all regions of the world, but are most concentrated in middle-and low-income countries [9].Burns are a major public health problem worldwide [10].The fatality rate for child burn victims in central Malawi is 27% [11].
The study shows that the magnitude of burns with complications in Ethiopia was 14.9% , the highest risk groups compared to children age groups and the elderly [12].In almost all age groups, the prevalence of burns is higher in women [13].The increase in burn risk in 3rd degree burns was more likely in case of wound infection and the risk of infection was also considered in burn surgery [14].Wound infection and septicemia were the two most common complications in burn patients [15].A burn contains both nociceptive and neuropathic pain components, so managing a burn is one of the most difficult challenges for the firefighting team [16].Treating a burn requires nursing staff many hours of wound care, possibly multiple surgical procedures, and expensive hospitalization [17].Burns are the most painful and require special attention and are considered a major public health problem [18].Burns are the fourth most common type of trauma causing death and disability after traffic accidents, falls and interpersonal violence [19].
Globally, burns are one of the leading causes of disability, accounting for more than 8 million disability-adjusted life years (DALYs) [20].In the United States, the direct cost burden of treating children with burns has exceeded $211 million.In Norway, the expenses of giving hospital burns exceeded 10.5 million euros.In South Africa, an estimated US$26 million is spent annually on burn injury, but indirect costs such as lost wages, long-term treatment for disfigurement and emotional trauma, and the contribution of family resources also contribute to socioeconomic impacts [21].Currently, most burn centers around the world care for patients based on a protocol [22].In the 20th century, advances in burn care lead to an increased focus on reducing burn morbidity.[23].Burns often result in significant psychological, educational and social stigma, and the resulting changes are exacerbated by many factors, including the circumstances of the burn, severity and location of the injury, personality characteristics of the injured person and access to support interpersonal communication, and social relations [24].
Both the patient and their family may experience physical and emotional suffering as a result of the burns and treatment [25].Burns are the second most common injury in rural Nepal, accounting for 5 percent of trees [7].It is estimated that over a million people burn in Africa each year and 18% of hospitalizations are due to burns [26].Burns are a common source of harm in developing countries including Ethiopia [27].The incidence of burns varies by country and population group, and the severity of the burn depends on the degree of heat, duration of exposure, and thickness of the skin [28].Burns occur mainly at home and in the workplace.As in Bangladesh and Ethiopia, show that 80-90% of burns occur in the home [29].In Ethiopia, the outcome of burn injury and associated factors among burn patients were not evidently described.
Hence, it needs more study to address the possible output of burn and sustaining uniform treatment protocol in health facility.Therefore, this study was assesses the outcome of burn injury and its associated factors at public hospital of North Shewa Zone, Amhara regional state.

Study design, setting and period
An institution-based cross-sectional study was conducted among 420 burn patients in public Hospital in North Showa zone, from April to May, 2023.Debre Berhan City is located 130-kilo meters from Addis Ababa, the capital city of Ethiopia and 696 km away from the Bahirdar city Regional state of Amhara.The total population of North Showa Zone was 2,322,148 of whom those 1,171,510 are men and 1,150,638 women for the year 2019.According to Zonal Health Office Report, North Shewa has 164 private clinics, 97 governmental health centers, 391 health posts, 8 primary Hospitals (of which two are private primary hospitals), 2 general hospitals, and one comprehensive specialized hospital North Shewa Zone has a total of 10 public and 2 private hospitals.

Populations Source Population: All patients who visited public hospital in North shoa zone
Study population: All burn patients who attended North shewa zone in selected public hospital from the 1st of January 2018 to December 30th 2022 in North Showa zone, Amhara, Ethiopia.

Inclusion and Exclusion criteria Inclusion criteria
All burn patients who attended North shewa zone public hospital, registered on patient card/medical record folders in hospital and his/her card/record was available in medical record unit/card room were included.

Exclusion criteria
Burn patients with incomplete records/information on either the burn or miss diagnosis upon review were excluded from the study.

Sample Size Determination and Sampling Techniques
Sample size for this study was determined by single population formulas.A study of outcome of burn injury and associated factor among patient visited at Addis Ababa, public hospital, the prevalence (p=54.7%)[12] ,with 5% margin of error, 95% CI and 10% non-response rate were considered.By adding a 10% non-response rate, the total sample size becomes 420.
There are 10 public hospitals in the North Showa Zone; from these, five were selected using a simple random sampling method.The medical record numbers (MRN) of the burn patient were used as a sampling frame.The sample was allocated proportionally for each hospital.Study participants were selected consuming a systematic random sampling technique.First, determined the sampling interval (K) value by dividing the total admitted burn patient in the study period by the total sample size, which gives 2.17 ≈ 2 as shown in Figure 2.
Variables (seen in Figure 1)

Operational definitions
Discharge with complication: In this study the patients have been discharged with one of the following; like contracture, disfigurement, amputated, scar of skin graft and death as reported on the chart considered as poor outcome of burn injury.

Burn patients:
A patient who sustained burn injury.
Burn injury: Is injury of skin or other tissue caused by thermal, radiation, chemical or electrical contact [30].
Type of burn injury: are classified by depth (superficial and deep partial thickness, and full thickness and TBSA are involved.
Outcome of burn injury: when the patients after Hospital management was discharged with complication or without complication as reported on the chart [31].

Data collection procedures
Data were collected using structured checklist adopted from national burn patients' medical record formats (patient card) available in medical record unit of public hospital at North shewa zone.All charts of burn patients with the diagnosed of burn in between January 1 st 2018 to December 30 th , 2022 at selective public hospital in north shewa were reviewed from patient registries.The checklists well prepared in English language, a language in which burn patients' medical record/patient card was written in.It contains information on socio-demographic conditions, clinical factors and health related factors.Data were extracted from patient medical record via record-review.

Data quality control and assurance management
Pre-test were done on 5% of the study samples on Hakim Gizaw hospital, is assumed to have similar characteristics to the study area, after the pre-test necessary correction was done on the checklist to amend language translation error and coherence of the checklist.Close supervision was conducted by principal investigator and one MPH in Epidemiology expert who had exposures and experience in the study setting.Data collectors and supervisors were trained for three days on ethics, data collection tool and how to review the medical records and handle the patient card itself.Data collection well supervised on daily basis.Filled data were checked daily by supervisors and principal investigator to minimize the errors that was created during review as early as possible.Data collectors were review recorded card in a separate place to keep privacy and confidentiality information.

Data Analysis procedures
The collected data were checked manually for any incompleteness and inconsistency.Data were entered using Epi-Data version 4.6 and analyzed using SPSS version 26.Descriptive statistics (frequency and percentage) for categorical predictors were done.Statistical association between each independent variable with dependent variable was assessed using bivariable logistics regression.In the bivariable analysis, a predictor with P-value<0.25 were considered for multivariable analysis.Model of fitness was assessed by Hosmer-Lemeshow test was not significant (0.212).The collinearitiy among independent variable were assessed by Variance inflation factor (1-2.5) those variables with a VIF of less than 10 were considered as no multicollinearitiy.Multivariable logistic regression analysis was conducted to identify factors significantly associated with outcome of burn injury.Significance of association was declared at a p-value of ≤ 0.05 within 95% CI.

Result Socio-demographic characteristics
A total of 408 participants participated with response rate of 97%.Among 408 participants 44.9 % were male.From the total of study participant (n=252) 68.3% were single, and

Cause of burn 212
In this study showed that flame (35.5%) were highly cause of burn injury, scalds (27.8%) were 213 the second cause of burn, steam (13.2%) were the third, chemical (10.7%) burn were the fourth 214 and electrical (12.8%) were the last cause of burn as seen in Figure 3.

Multivariate logistic regression
Data were analyzed using binary logistic regression analysis.Statistical associations were checked by 95% CI and odds ratio.Those variables which had a p-value less than 0.25 in the binary logistical regression analysis were eligible for multivariable logistic regressions.Finally, the adjusted odds ratio was checked and the significant variables p value<0.05 were considered as associated factors for burn outcome of discharged with complication.
Patients who had pre-hospital intervention was nearly four (AOR= 3.8, 95% CI, 1.11-13.25)times more likely to develop discharged with complication compared to patients who have not pre-hospital intervention.Similarly, this study revealed that the outcome of burn injury discharged with complication was (AOR= 4.3, 95% CI, 1.52-12.32)times more likely burn in scalds compared to patients with electrical, chemical and flame burn.
Patients who had provided fluid and electrolyte were 76% less likely to the outcome of burn injury discharged with complication than patients who had not use fluid and electrolyte (AOR= 0.24, 95%CI, 0.10-0.56).Similarly, the occurrence of TBS area less than twenty percent burned were 66% less likely to the outcome of burn injury discharged with complication compared to patients TBS area burned greater than twenty one percent (AOR= 0.34, 95%CI, 0.14-0.82)as shown in table 4. complication.But, this finding consistent with study done in Haromia University [35].Another studies conducted in Tanzania and Nepal revealed different result [36] [37].The reason might be duo to study population, area of study, period and time of data collection could be a reason for this difference.In this study the most frequent cause of injury is flame which accounts for 35.5% followed by scalds, steam, electrical and chemical burn.The result of this study congruent with studies done in Gonder, Ethiopia and Tanzania [36,38].But this study contradicts to studies in Addis Ababa burn, emergency and trauma hospital and Ayder referral hospital, Mekelle city [32,34].The possible justification might be due to population distribution at study area and cultural variation between populations to population.In this study flame burn is the number one cause for the study population followed by scalds, steams, electrical and chemical burns.
In this finding the affected body surface area (TBSA (%) due to burn injury is an important feature in the determination of the burn injury.From the study participants 79% patients had burn extent of less than 20% of TBSA.Finding of this study revealed that the occurrence of TBS area less than twenty percent burned were 66% less likely to discharge with compilation as compared to patients TBS area burned greater than twenty-one percent.Which is in line with the study showed in Bahir Dar [33].This marks in resulting to decline intravascular hypervolemia which can produce complication like ischemia to body organs.Similarly, patients who had provided fluid and electrolyte were 76% less likely to the outcome of burn injury discharged with complication than patients who had not use fluid and electrolyte during hospital stay.The finding also congruent with study done in Ayder referral hospital, Mekelle city [32].This could implicate that increasing public awareness regarding health seeking behavior and early admission for intera-veins infusion can diminish complication.This confirmed that patients established timely supportive interventions, related to fluid and electrolyte resulting in fewer burn complications.Patients who had pre-hospital intervention were three point eight times more likely the outcome of burn injury discharged with complication then patients who have not prehospital intervention.This finding was not equivalent with studies conducted in Haromia and Tanzania [35] , [36].The reason might be due to the difference of preexisting medical condition before arriving at health institution, extent and depth of burn injury, cultural tradition among burn management and quality of care in the community.Patients who sustained scald burn were four point three times more likely the outcome of burn injury discharged with complication as compared to patients with electrical, chemical and flame burn.This finding supported with study conducted in South Gondar zone government hospitals, Ethiopia [38].But this result different from study done in Buganda Medical Centre in Northwestern Tanzania, that showed flame, electrical and chemical burn were more likely complication as compared to scald burn [36].The difference might be duo to sample size, study population, life style and socio-cultural because of those cause which are prone to different burn injury.

Conclusion
This study demonstrates a significantly higher level of the outcome of burn injury discharged with complication, leading to increased death and other worst outcomes.Having pre-hospital intervention and the cause of burn with scalds were significant factors associated with discharged with complication.Early fluid and electrolyte provided and having TBS area less than twenty percent as a protective effect for patients with poor outcome of burn injury.

Recommendation
To health professionals  -Encourage health education on pre-hospital intervention to prevent and perform initial intervention for patients with burn injury.Increase the awareness and impact of scald burn for clients as well as the community.
 -Focus to providing fluid and electrolyte for patients need to hospital admission and their total body surface area affected more than twenty percent.

To the regional health office
 -There should be well equipped burn units to reduce poor outcome of burn injury.

To researchers
 -Recommend for further case control studies that determine the risk factor, for poor outcome of burn injuries.

Limitation of the study
This study has a number of restrictions.The first drawback is that a few variables are absent from the typical burn registration books.Unable to determine the precise number of burn patients who were hospitalized or discharged because the data is retrospective.

Ethical Approval
Ethical approval and clearance were obtained from the institutional review board (IRB) of Asrat Woldeyes Health Science Campus Permission was obtained from Zonal health office, and selected hospital chief-executive officer.All aspects of basic ethical research principles were addressed, so the study participants were selected based on the research requirements.
The study participant name was not be written in the questionaries' form and never be used in connection with any information you tell us.All information given by the study participant was kept strictly confidential.Codes and aggregate reporting were used to eliminate names and other personal identifiers of respondents throughout the study process to ensure anonymity.

Outcome of burn injury
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Figure 1 :FigureFigure 2 :Figure 3
Figure 1:-Conceptual frame work for a study on the outcome of burn injury and its associated factors among burn patient at public hospital in North shewa zone, 2023 [1-4].

Figure 4
Figure 4 Schematic presentation of the proportion on poor outcome among burn patients attending at public Hospitals in north shewa zone amhara region Ethiopia 2023(n=408).

Table 1 :
30.1% were married.Most of them were government employed and students.Most of the participant was at 191 home when burn happened seen in table 1. Socio-demography characteristics of participants at public Hospitals in north shewa In this study the main circumstances of surrounding burn 98.8% participants were through 196 accident and the remaining 1.8 % was assault.Most of the participant have been superficial 197 thickness burn (71.6%), 27.5% participants had partial thickness burn and only 1% participants 198 have been full thickness burn injury.From the participant 5.1% were having been comorbidity 199 with Epilepsy.Among the study participants 10.3 were had pre-hospital intervention described as 200 192

table 2 . 201 Table 2 :
Health related factors of participants at public Hospitals in north shewa zone amhara From the participant admitted in hospital 75.2% were staying less than fifteen day.Participants 205 during hospital stay 22.1% were took fluid and electrolyte, 22.3% were have been wound 206 management and most of them were used antibiotic.From the participants their outcome of burn 207 injury with complication 15.1% had disability, 20.5 death and 64.4 were have been scaring as 208shown in table3.209

Table 3 :
clinical factors of participants at public Hospitals in north shewa zone amhara region

Table 4 :
Bi-variable and multivariable logistic regression on poor outcome of burn injury among burn patients attending at public Hospitals in north shewa zone amhara region Ethiopia 2023(n=408).Abeba Yekatit 12 Hospital, Ethiopia, 13.3% and 17.3% were poor outcome of burn injury [32, 247 33].The possible reason might be duo to study area, dated of time and the sampling unit.
241 complication.Having pre-hospital intervention, patients with scalds burn, early fluid and 242 electrolyte provided and having total body surface area <20% were significant factors associated 243 with discharged with complication.In this study, the proportion of the outcome of burn injury 244 discharged with complication was 40.9% (95% CI: 36.5-45.6).The result of this finding high as 245 compared to studies in Ayder referral hospital, Mekelle city, Tigria regional state and Addis 246 252 equipped infrastructure at health institution specifically for burn injury patients, it might be a 253 reason for low proportion of burned patients with the outcome of burn injury discharged with 254